| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,348 |
1,345 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
650 |
649 |
$26K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
405 |
190 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
154 |
154 |
$14K |
| D1110 |
Prophylaxis - adult |
255 |
254 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
893 |
890 |
$5K |
| D1206 |
Topical application of fluoride varnish |
1,672 |
1,667 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,722 |
966 |
$2K |
| D1330 |
|
1,596 |
1,591 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
1,082 |
1,069 |
$839.56 |
| D0272 |
Bitewings - two radiographic images |
304 |
304 |
$501.80 |
| D9999 |
Unspecified adjunctive procedure, by report |
13 |
13 |
$325.00 |
| D0274 |
Bitewings - four radiographic images |
108 |
108 |
$216.40 |
| D1351 |
Sealant - per tooth |
278 |
66 |
$0.00 |